It's time to act against silent deaths from methanol poisoning

Earlier this year, Md. Hasan Seikh, aged 20, and Binoy Deb, aged 25, from a village in Pabna, diedmysteriously and suddenly afterdrinking what they and their friends thoughtwas regular alcohol. Haider Biswas, aged 24,a friend of Mr. Hasan, narrowly escaped his friend's fate. However, he lost his vision wholly and irreversibly. Their families, trying to put the deadly clues together,still struggle to make sense of what happened. 

Almost overnight,these young men went from healthy and in the prime of life, with bright futures ahead, to permanently disabled or dead after consuming what we can confidently assume was methanol poisoning.While each was taken to the District Hospital and two of them later to the nearest Medical College,the diagnosis and treatment of their condition werefragmented and sparse.Tragically, their deaths and disability were largely avoidable had they received the needed medical treatment in time. 

Although mostly prohibited in Bangladesh, what people usually drink as alcohol are beverages with ethanol as the main active ingredient. Although consuming ethanol-containing beverages can lead to long-term chronic health conditions, accidents, and sometimes alcohol poisoning when over-consumed, the human body is well-equipped to deal with ethanol in short-term.  What is methanol?  Methanol is a close cousin of ethanol but has a slightly different chemical structure. It contains only one carbon atom, forming a methyl group (-CH?), whereas ethanol contains two carbon atoms, forming an ethyl group (-CH?CH?). However, while the human body can metabolize ethanol, it converts methanol into the toxic substance formate. This toxin poisons the body, disrupting the acid balance and interfering with the optic nerve, leading to blindness, and other organs such as the brain, heart, lungs, kidneys, and liver. Symptoms, which may not set in hours-or even days-after consuming the contaminated substance, can include vision issues, nausea and vomiting, difficulty breathing, drowsiness, confusion, seizures, and loss of consciousness. Without timely treatment, the tragic result is all too often death or permanent disability.

Over the past year, the Toxicology Society of Bangladesh has been collaborating with the Bangladesh Medical University and the University of Edinburgh to better understand the neglected issue of methanol poisoning in Bangladesh. Interestingly, we often read about these incidents in our national dailies. There is a formula to these reports: usually, they report on people dying as a result of drinking 'toxic alcohol' along with statements from health officials and the local police department. Such incidents often occur especially duringmajor social and religious festivals. But thereportsrarely name the source of this toxicity. The fact remains that despite people's familiarity with alcoholic beverages, few are aware of the potential danger of methanol contamination. It remains a mysterious phenomenon to all.  

Although mostly prohibited in Bangladesh, what people usually drink as alcohol are beverages with ethanol as the main active ingredient. Although consuming ethanol-containing beverages can lead to long-term chronic health conditions, accidents, and sometimes alcohol poisoning when over-consumed, the human body is well-equipped to deal with ethanol in short-term. 

A team from our project, entitled Preventing Deaths from Acute Poisoning in Low- and Middle-Income Countries, is working to improve the diagnosis and treatment of methanol poisoning, which is claiming the lives and health of far too many in the country. While part of this work involves testing the introduction of a point-of-care test (POCT) to detect methanol poisoning and streamline treatment, significant progress can still be made even without such a diagnostic technology. 

Indeed, even without this device, there is still much the health system can do to fulfil its responsibilities. One thing we have found through our work is that people want better care from health facilities in the case of methanol poisoning, but much of the barrier lies with health service managers and providers, who are ill-prepared to identify and treat those who may be experiencing methanol poisoning. In particular, we found that health actors are hesitant to use ethanol, the internationally accepted and Bangladesh national guideline-approved antidote for treating such poisoning cases. Lack of access to ethanol for medical purposes and social acceptance make it difficult for the health service providers to use this specific antidote. 

While Fomepizole offers a gold-standard treatment and is included on the World Health Organization's Essential Medicines list, it is currently unavailable in Bangladesh and expensive. With more acceptance, however, ethanol can offer a practical and immediately available alternative to mitigate the deadly effects of methanol poisoning. Timely treatment is of the essence, and national guidelines recommend that patients suspected of experiencing methanol poisoning should be treated with ethanol.

While we all know that the Bangladeshi health system faces many challenges, we cannot continue to allow those experiencing methanol poisoning to die or suffer lifelong disability due to inactionon our part. The health system has a responsibility to do its best to save them from excruciating pain and suffering. Health service providers and managers need support to build their capacity to fulfil these responsibilities to care for those experiencing this form of poisoning, such asthorough training on the national guideline and ensuring logistical (e.g., access to ethanol) and practical support (e.g., having a specific protocol, security measures).This would be fundamental to the duty of care with which they have beenentrusted.